Research Article
Arch Neuropsychiatr 2015; 52: 145-50 • DOI: 10.5152/npa.2015.7419
Antipsychotic Use Pattern in People with Psychotic Disorder Living in Board and Care Facilities Etem Erdal ERSAN1, Mustafa YILDIZ2 1 2
Clinic of Psychiatry, Numune Hospital, Sivas, Turkey Department of Psychiatry, Kocaeli University Faculty of Medicine, Kocaeli, Turkey
ABSTRACT Introduction: The aim of this survey is to determine the pattern of antipsychotic drug use in patients with psychotic disorders, living in board and care facilities and to investigate the related factors. Methods: We evaluated the antipsychotic drug use pattern in outpatients with psychotic disorders according to DSM-IV, living in board and care facilities. Patients using polypharmacy at least one month were compared with patients using monotherapy in terms of clinical and demographic characteristics. Results: Antipsychotic polypharmacy (with two: 34%, with more than two: 28%) was identified in 62% of the patients. The most frequently prescribed combination was olanzapine+quetiapine (13%), the rate of first and second generation combination was 50%, the rate of second generation antipsychotic combination was 44%, and the rate of first
generation anytipsychotic combination was 4% in the two antipsychotic drug combination group. The rate of clozapine use was 3%. Use of polypharmacy was associated with the diagnosis of schizophrenia and schizoaffective disorder, young age, suicidal behavior, multiple hospitalizations, clinical severity, and the need of anticholinergic drug. Conclusion: The ratio of using more than two antipsychotic drug combination is high (28%) in psychotic patients living in board and care, and rate of clozapine use is low, which shows that clinical practice is inconsistent with the treatment guidelines recommendations. It appears that further education to rationale antipsychotic drug use in psychiatric practices is required. Keywords: Psychotic disorder, schizophrenia, antipsychotics, polypharmacy, monotherapy, outpatient, board and care facility
INTRODUCTION Guidelines for treating patients with psychotic disorder (1) have consistently recommended antipsychotic monotherapy (APMT) as the treatment of choice; however, polypharmacy (APPP) is widespread in daily clinical routine (1). Although studies are not sufficient, polypharmacy has been used for a long time in clinical practices (2). Schizophrenia is a chronic and mainly treatment-resistant disease, in which treatment response is limited, drugs have side-effects, drug potentiation is generally needed on the basis of clinical experience, APMP is not attempted in sufficient doses, doctors want to observe rapid clinical improvements, psychotic anxiety causes difficulties, and patients want to be discharged from hospital in a short-time. Because of these factors, antipsychotic drugs (APDs) are mainly used in combination (2,3,4,5). New generation APDs again lead to polypharmacy for schizophrenia patients (4). According to the guidelines for treating patients with schizophrenia, when patients fail to respond to an adequate dose of an antipsychotic trial during an adequate period, combinations may be used. According to these guidelines, polypharmacy is optimal only for resistant patients and during antipsychotic switching periods (6,7,8). The Texas Medication Algorithm recommends polypharmacy after three monotherapy regimes including clozapine (8). The Schizophrenia Treatment Guideline of Psychiatric Association of Turkey suggests that APMT is important, but their view is line with the Texas Medication Algorithm in terms of polypharmacy (9). The controlled studies on APPP are not sufficient. Therefore, we should avoid from routine polypharmacy. In previous studies, a few patients have benefited from APPP; however, the prevalence of APD combination is 10–75% in schizophrenia patients (10,11,12,13,14,15). In the studies performed in Turkey, the prevalence of APD combinations is similar (16,17,18,19,20). APD combinations are frequently used, but evidence-based data are lacking, and antipsychotic polypharmacy is not found to be superior than monotherapy (21). Several studies have shown that the drug–drug interactions of APPP cannot be considered as safe; it is also expensive and increases mortality rate in schizophrenia patients (22,23,24). We should cautiously consider mortality risk, risk-benefit, and cost-expense profile of APD use before polypharmacy trial (25). Correspondence Address: Dr. Mustafa Yıldız, Department of Psychiatry, Kocaeli University Faculty of Medicine, Kocaeli, Turkey Phone: +90 533 747 50 42 E-mail: [email protected] Received: 15.09.2013 Accepted: 07.01.2014 ©Copyright 2015 by Turkish Association of Neuropsychiatry - Available online at www.noropskiyatriarsivi.com
145
Ersan and Yıldız. Antipsychotic Usage in Board and Care Patients
Arch Neuropsychiatr 2015; 52: 145-50
Table 1. The demographic and clinical characteristics of the patients and associations with mono or polytherapy use Characteristics Sex (male)
Number 129
Percent
Mean±SD (range)
Statistics
64.5
Age
43.8±12.1 (16–81)
Education
6.2±3.2 (0–15)
Marriage status (married)
20
10.0
Occupation (not working)
173
86.5
Family support (none)
123
61.5
Physical disease (none)
165
82.5
Physical violence
75
37.5
Suicide attempt
40
20.0
p
Arch Neuropsychiatr 2015; 52: 145-50 • DOI: 10.5152/npa.2015.7419
Antipsychotic Use Pattern in People with Psychotic Disorder Living in Board and Care Facilities Etem Erdal ERSAN1, Mustafa YILDIZ2 1 2
Clinic of Psychiatry, Numune Hospital, Sivas, Turkey Department of Psychiatry, Kocaeli University Faculty of Medicine, Kocaeli, Turkey
ABSTRACT Introduction: The aim of this survey is to determine the pattern of antipsychotic drug use in patients with psychotic disorders, living in board and care facilities and to investigate the related factors. Methods: We evaluated the antipsychotic drug use pattern in outpatients with psychotic disorders according to DSM-IV, living in board and care facilities. Patients using polypharmacy at least one month were compared with patients using monotherapy in terms of clinical and demographic characteristics. Results: Antipsychotic polypharmacy (with two: 34%, with more than two: 28%) was identified in 62% of the patients. The most frequently prescribed combination was olanzapine+quetiapine (13%), the rate of first and second generation combination was 50%, the rate of second generation antipsychotic combination was 44%, and the rate of first
generation anytipsychotic combination was 4% in the two antipsychotic drug combination group. The rate of clozapine use was 3%. Use of polypharmacy was associated with the diagnosis of schizophrenia and schizoaffective disorder, young age, suicidal behavior, multiple hospitalizations, clinical severity, and the need of anticholinergic drug. Conclusion: The ratio of using more than two antipsychotic drug combination is high (28%) in psychotic patients living in board and care, and rate of clozapine use is low, which shows that clinical practice is inconsistent with the treatment guidelines recommendations. It appears that further education to rationale antipsychotic drug use in psychiatric practices is required. Keywords: Psychotic disorder, schizophrenia, antipsychotics, polypharmacy, monotherapy, outpatient, board and care facility
INTRODUCTION Guidelines for treating patients with psychotic disorder (1) have consistently recommended antipsychotic monotherapy (APMT) as the treatment of choice; however, polypharmacy (APPP) is widespread in daily clinical routine (1). Although studies are not sufficient, polypharmacy has been used for a long time in clinical practices (2). Schizophrenia is a chronic and mainly treatment-resistant disease, in which treatment response is limited, drugs have side-effects, drug potentiation is generally needed on the basis of clinical experience, APMP is not attempted in sufficient doses, doctors want to observe rapid clinical improvements, psychotic anxiety causes difficulties, and patients want to be discharged from hospital in a short-time. Because of these factors, antipsychotic drugs (APDs) are mainly used in combination (2,3,4,5). New generation APDs again lead to polypharmacy for schizophrenia patients (4). According to the guidelines for treating patients with schizophrenia, when patients fail to respond to an adequate dose of an antipsychotic trial during an adequate period, combinations may be used. According to these guidelines, polypharmacy is optimal only for resistant patients and during antipsychotic switching periods (6,7,8). The Texas Medication Algorithm recommends polypharmacy after three monotherapy regimes including clozapine (8). The Schizophrenia Treatment Guideline of Psychiatric Association of Turkey suggests that APMT is important, but their view is line with the Texas Medication Algorithm in terms of polypharmacy (9). The controlled studies on APPP are not sufficient. Therefore, we should avoid from routine polypharmacy. In previous studies, a few patients have benefited from APPP; however, the prevalence of APD combination is 10–75% in schizophrenia patients (10,11,12,13,14,15). In the studies performed in Turkey, the prevalence of APD combinations is similar (16,17,18,19,20). APD combinations are frequently used, but evidence-based data are lacking, and antipsychotic polypharmacy is not found to be superior than monotherapy (21). Several studies have shown that the drug–drug interactions of APPP cannot be considered as safe; it is also expensive and increases mortality rate in schizophrenia patients (22,23,24). We should cautiously consider mortality risk, risk-benefit, and cost-expense profile of APD use before polypharmacy trial (25). Correspondence Address: Dr. Mustafa Yıldız, Department of Psychiatry, Kocaeli University Faculty of Medicine, Kocaeli, Turkey Phone: +90 533 747 50 42 E-mail: [email protected] Received: 15.09.2013 Accepted: 07.01.2014 ©Copyright 2015 by Turkish Association of Neuropsychiatry - Available online at www.noropskiyatriarsivi.com
145
Ersan and Yıldız. Antipsychotic Usage in Board and Care Patients
Arch Neuropsychiatr 2015; 52: 145-50
Table 1. The demographic and clinical characteristics of the patients and associations with mono or polytherapy use Characteristics Sex (male)
Number 129
Percent
Mean±SD (range)
Statistics
64.5
Age
43.8±12.1 (16–81)
Education
6.2±3.2 (0–15)
Marriage status (married)
20
10.0
Occupation (not working)
173
86.5
Family support (none)
123
61.5
Physical disease (none)
165
82.5
Physical violence
75
37.5
Suicide attempt
40
20.0
p
